Introduction

Chronic obstructive pulmonary disease (COPD) is a condition which causes symptoms such as breathlessness, cough and sputum production.These symptoms often lead to a reduced ability to carry out normal day to day activities.However, COPD is also a condition which can be terminal, leading for the need to consider palliative care and appropriate approaches to the end of life.In this case study, we will consider some of current approaches to end of life care in COPD.

Section 1 Peter is 82 years old and has had COPD for 25 years. He is an ex-smoker with a 60 pack year history. He is on triple therapy (an inhaled corticosteroid at 800mcg total daily dose equivalence combined with a long acting beta2 agonist along with a long acting muscarinic antagonist) but is still very symptomatic with an MRC dyspnoea score of 5 (modified MRC of 4) and a COPD assessment test score of 32. Both of these indicate that his COPD is having a significant impact on his life. He spends most of his time in his chair or in his bed, which has been moved downstairs. He lives with his 80 year old wife and they have once daily visits from carers at bedtime. Over the past six months he has been admitted to hospital with breathlessness on two occasions and has had 3 courses of prednisolone.

Based on the information we have here, what is happening with Peter?

He is poorly controlled and needs to increase the dose of his inhaled corticosteroid

He is approaching end of life and needs managing as such

He needs assessing for comorbidities which may be impacting on his symptoms

He needs an oxygen assessment

indicates the correct answers for this question

Explanation

Section 1 Peter is 82 years old and has had COPD for 25 years. He is an ex-smoker with a 60 pack year history. He is on triple therapy (an inhaled corticosteroid at 800mcg total daily dose equivalence combined with a long acting beta2 agonist along with a long acting muscarinic antagonist) but is still very symptomatic with an MRC dyspnoea score of 5 (modified MRC of 4) and a COPD assessment test score of 32. Both of these indicate that his COPD is having a significant impact on his life. He spends most of his time in his chair or in his bed, which has been moved downstairs. He lives with his 80 year old wife and they have once daily visits from carers at bedtime. Over the past six months he has been admitted to hospital with breathlessness on two occasions and has had 3 courses of prednisolone.

Answer C is correct. Peter's smoking history increases his risk of a range of other conditions and he is at higher risk of comorbidities such as heart failure because of his COPD (GOLD 2017). A careful history with examination and investigations as appropriate will ensure that co morbidities are identified and treated. Increasing his dose of ICS would not be appropriate as there are set ICS doses for COPD relating to each licensed product and they are not flexible as they are in asthma. It is important not to assume end of life before other possible diagnoses are considered. As we do not know Peter’s SATs we cannot know whether an oxygen assessment is required or not.

Section 2 The Gold Standards Framework (GSF 2011) includes key prognostic indicators for people with end stage COPD who may need palliative care. These may include BMI, oxygen saturations and frequency of exacerbations.

What does FEV₁ tell us about prognosis?

It doesn’t tell us anything, it is simply a measure of airflow limitation

An FEV₁ less than 30% predicted indicates very severe airflow obstruction and is associated with a poor prognosis

An FEV₁ less than 30% predicted indicates severe airflow obstruction and is associated with a poor prognosis

An FEV₁ less than 50% predicted indicates severe airflow obstruction and is associated with a poor prognosis

indicates the correct answers for this question

Explanation

Section 2 The Gold Standards Framework (GSF 2011) includes key prognostic indicators for people with end stage COPD who may need palliative care. These may include BMI, oxygen saturations and frequency of exacerbations.

Answer B is correct (GSF 2011) Although FEV₁ may not help with management decisions in stable COPD, an FEV₁ of less than 30% predicted indicates very severe airflow obstruction and is associated with a poor prognosis. This is particularly true when associated with a low BMI, low oxygen SATs and frequent exacerbations.

Section 3 Peter is very breathless despite his triple therapy with two long acting bronchodilators and regular use of his short acting beta2 agonist. His SATs are 94% at rest on air.

Which cost-effective option might help with Peter’s symptoms and offer the best risk: benefit ratio?

A hand held fan

Short burst oxygen

Long term oxygen therapy

A referral for oxygen assessment

indicates the correct answers for this question

Explanation

Section 3 Peter is very breathless despite his triple therapy with two long acting bronchodilators and regular use of his short acting beta2 agonist. His SATs are 94% at rest on air.

Answer A is correct. In the absence of hypoxia, oxygen assessment, short burst oxygen and long term oxygen therapy are less cost-effective and have safety concerns as well. NICE does not recommend oxygen therapy for people who are not hypoxic although GOLD does suggest that oxygen may be helpful in some people even if they are not hypoxic. Hand held fans, however, combine efficacy with safety.

Section 4 Peter’s BMI is 18.2 and he has lost a stone in the past months. Investigations have revealed no sinister cause for his weight loss and it is thought to be due to the extra energy expenditure from his severe breathlessness. The Malnutrition Universal Screening Tool (MUST) puts him in the red (high risk) category.

Which one of the following is not recommended at this stage?

Adding cream to meals to increase the calorie content without adding bulk

Offering a high calorie, high protein, low volume supplement

Offering a dietician referral

Encouraging a healthy normal diet

indicates the correct answers for this question

Explanation

Section 4 Peter’s BMI is 18.2 and he has lost a stone in the past months. Investigations have revealed no sinister cause for his weight loss and it is thought to be due to the extra energy expenditure from his severe breathlessness. The Malnutrition Universal Screening Tool (MUST) puts him in the red (high risk) category.

Answer D would not be appropriate as Peter is severely breathless, suffering from malnutrition and finds it hard to eat normal meals. More information can be found at the COPD malnutrition pathway (www.malnutritionpathway.co.uk/copd/).

Section 5 The palliative care team have suggested oramorph to assist with Peter’s breathlessness.

What does GOLD say about this?

Opiates should be avoided as they cause respiratory depression

Oramorph® (morphine sulfate) is only licensed for pain so should only be prescribed for pain, not breathlessness.

Opiates can help to relieve breathlessness but the evidence is limited and the product is not licensed (grade C)

Opiates can help to relieve breathlessness and the evidence is strong (grade A)

indicates the correct answers for this question

Explanation

Section 5 The palliative care team have suggested oramorph to assist with Peter’s breathlessness.

Answer C is correct. According to GOLD, the evidence for opiates in breathlessness is level C although there are studies, such as the one by Ekstrom et al (2015) showed that oramorph 2.5mg bd to qds helped to relieve breathlessness, quality of life and exercise capacity in people with COPD. However, non-palliative care clinicians may be reluctant to prescribe them for a range of reasons (Young et al 2012)

Summary

People with end stage COPD can suffer from a range of debilitating symptoms akin to those suffered by those with lung cancer but they are not always able to access the same support services, such as hospice care. Optimisation of care is best achieved through multi-disciplinary working with input from both respiratory and palliative care experts.

Jack was able to relieve some of his symptoms with a small dose of oramorph, a hand held fan and some supplements for his malnutrition. The multi-disciplinary team worked together to ensure that he and his wife were offered holistic care which included physical, spiritual and financial support.

Overall score

Your final score for this case study is

While you will find that working through the site in this way is an effective way for you to develop your knowledge, you might also be interested in developing your practical skills too. Last year nearly 5000 health professionals chose distance learning with Education for Health to improve their competence and confidence in treating and managing patients with long-term conditions.

For more information on how Asthma, COPD and Allergy education can help you to achieve your goals please visit the resource page

You score qualifies you to download a certificate of completion. Just enter your name below and click continue to download your certificate.

This website is supported by an unrestricted educational grant from Teva Respiratory

This website is supported by unrestricted educational grant from Teva UK Limited. Teva UK Limited has reviewed the content for factual accuracy. | KOL/11/028(1) Date of preparation December 2015 Editorial control of educational content remains with Education for Health.